Outpatient Pharmacy Clause Samples

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid/WVCHIP. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS as appropriate for FFS coverage, and Hepatitis-C virus (HCV)-related drugs will be covered by FFS Medicaid/WVCHIP. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid and WVCHIP. BMS will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations. The MCO is permitted to negotiate and collect supplemental rebates with drug companies for provider-administered drugs. The MCO’s provision for physician discretion and the medical needs of the patient must not be impaired by rebate agreements. The rebate amount shall be accounted for in the MLR calculation. The MCO shall comply with Section 1004 of the SUPPORT for Patients and Communities Act and the Drug Utilization Review (DUR) regulations as described in section 1927(g) of the Act and 42 CFR part §456, subpart K. The MCO shall be subject to both prospective and retrospective requirements, as applicable, dependent on whether the medication is administered via point of sale or clinically. The MCO must comply with all established criteria required by BMS before approving the initial coverage of any physician administered agent which is currently available in a point-of-sale form. If exceptions to the criteria are considered appropriate or necessary, the MCO must obtain written consent for such variance from BMS Office of Pharmacy Services. The MCO shall be subject to following provisions of Section 1004 of the SUPPORT for Patient and Communities Act:

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by DHHR as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid. The Department will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all other provider-administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations.

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age 21, and prenatal vitamins) are covered by the MCO. Hemophilia-related clotting factor drugs will be covered by the fee-for-service Medicaid program. Drugs and supplies dispensed by a physician acquired by the physician at no cost are not covered by Medicaid.

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by fee-for-service Medicaid. Hemophilia-related clotting factor drugs and Hepatitis-C virus-related drugs will be covered by fee-for-service Medicaid. Drugs and supplies dispensed by a physician acquired by the physician at no cost are not covered by Medicaid. The Department will provide the MCO with pharmacy utilization data to support coordination of care for the member. The MCO remains responsible for all physician-administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations.

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age twenty-one (21), and prenatal vitamins) are covered by FFS Medicaid. Hemophilia-related clotting factor drugs, Spinraza, other drugs deemed by BMS as appropriate for FFS coverage, and Hepatitis-C virus-related drugs will be covered by FFS Medicaid. Drugs and supplies dispensed by a physician, acquired by the physician at no cost, are not covered by Medicaid. BMS will provide the MCO with pharmacy utilization data to support coordination of care for the enrollee. The MCO remains responsible for all physician-administered drugs, such as those provided as part of an inpatient stay, a bundled ER visit, or administered vaccinations.

Outpatient Pharmacy. Simple or compound substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance (e.g., prescription drugs, family planning supplies, vitamins for children to age 21, and prenatal vitamins) are covered by the fee-for-service Medicaid program. Hemophilia-related clotting factor drugs will be covered by the fee-for-service Medicaid program. MCO physicians may prescribe prescription drugs or other above-listed drugs and supplies to MCO enrollees, who may then fill the prescription at any pharmacy that accepts Medicaid by presenting their Medicaid card. Drugs and supplies dispensed by a physician acquired by the physician at no cost are not covered by fee-for-service Medicaid.